Request for Reasonable Accommodation

NameTelephone

Address

CityStateZip Code

Status: StudentFacultyOther(Please Explain)

(Complete form onscreen, print, sign and submit to UNK Human Resources)

Accommodation(s) Requested: (Press Enter/Return at the end of each line)
 
I hereby grant permission to the health care professional to provide the University of
Nebraska-Kearney all medical/psychological information to make a decision on
reasonable accommodation.

I understand that it is my responsibility to provide this signed document along with the
formal job description and medical/psychological diagnosis form to the health care professional(s).
If I do not provide these documents, the University of Nebraska-Kearney
will not proceed with my request for reasonable accommodation.

_________________________________
Employee Signature and Date